NOVEMBER 2014 HEALTH INSURANCE CHOICES FOR

Transcription

1 NOVEMBER 2014 HEALTH INSURANCE CHOICES FOR 2015 For Employees of the State of New York who are unrepresented or in Negotiating Units that have agreements/awards with New York State effective October 1, 2011 or later, Participating Employers, their Enrolled Dependents, COBRA Enrollees with their NYSHIP benefits and Young Adult Option Enrollees. (Check with your agency Health Benefits Administrator or union if you are uncertain). Choices 2015/Settled Actives a

2 TABLE OF CONTENTS Make Your Health Plan Choices...i Rates and Deadline for Changing Plans...i Changing Your Pre-Tax Contribution Program Status...1 Your Share of the Premium...2 Let Your Agency Know about Changes...2 Retiring or Leaving State Service in 2015?...2 Eligible for Medicare?...2 Comparing Your NYSHIP Options...3 Benefits...3 Exclusions...3 Geographic Area Served...3 Benefits Provided by All Plans...4 Medicare and NYSHIP...5 The Empire Plan or a NYSHIP HMO What s New?...6 Summary of Benefits and Coverage...8 Making a Choice...9 Plan Similarities and Differences Terms to Know NYSHIP s Young Adult Option...13 Questions and Answers...14 Opt-out Program...15 Plans by County The Empire Plan Benefit Chart NYSHIP HMO Benefit Charts NYSHIP Online INFORMATION & REMINDERS MAKE YOUR HEALTH PLAN CHOICES This booklet explains the options available to you under the New York State Health Insurance Program (NYSHIP) for your health insurance and other elections. You may choose coverage under either The Empire Plan or one of the NYSHIP-approved Health Maintenance Organizations (HMOs) in your area. Or, if you can be covered under other employer-sponsored group health benefits, you may be eligible to elect the Opt-out Program. Consider your options carefully. You may not change your option after the deadline except in special circumstances. (See your NYSHIP General Information Book and Empire Plan Reports or HMO Reports for details about changing options outside the Option Transfer Period). If you have questions after you have read the information in this booklet, contact your agency Health Benefits Administrator (HBA) or The Empire Plan administrators and HMOs directly. RATES FOR 2015 AND DEADLINE FOR CHANGING PLANS The Empire Plan and HMO rates for 2015 are mailed to your home and posted on our web site, NYSHIP Online, as soon as they are approved. Select your group if prompted, and then click on Health Benefits & Option Transfer. Choose Rates and Health Plan Choices. (Note: Participating Employers, such as the Thruway Authority and the Metropolitan Transportation Authority, will notify their enrollees of 2015 rates). The rate flyer announces the option change deadline and paycheck deduction dates. You have 30 days from the date your agency receives rate information to make a decision. Your agency HBA can help if you have questions. COBRA and Young Adult Option Enrollees may contact the Employee Benefits Division at or (U.S., Canada, Puerto Rico and the Virgin Islands). i Choices 2015/Settled Actives

3 CHANGING YOUR 2015 PRE-TAX CONTRIBUTION PROGRAM STATUS (NOVEMBER 30, 2014 DEADLINE) Pre-Tax does not apply to COBRA and Young Adult Option Enrollees. Under the Pre-Tax Contribution Program (PTCP), your share of the health insurance premium is deducted from your wages before taxes are withheld, which may lower your tax liability. NO ACTION IS REQUIRED TO KEEP YOUR CURRENT PTCP STATUS. Your paycheck shows whether or not you are enrolled in PTCP. If you are enrolled in PTCP, your paycheck stub shows Regular Before-Tax Health in the Before- Tax Deductions section. If you are not enrolled in PTCP, your paycheck stub shows Regular After-Tax Health in the After-Tax Deductions section. Your health insurance premium is deducted from your wages after taxes are withheld. New Enrollees New enrollees must elect whether or not to participate in PTCP when enrolling for NYSHIP coverage. No election will be made automatically on the enrollee s behalf. Your enrollment cannot be completed until you make a PTCP election. PTCP Enrollment Limits Mid-Year Changes Under Internal Revenue Service (IRS) rules, if you are enrolled in PTCP, you may change your pre-tax payroll deduction for health benefits during the tax year only after one of the following PTCP-qualifying events: Change in employee s marital status Change in employee s number of dependents Change in employment status of employee, spouse or dependent that affects eligibility for health benefits Dependent satisfies or ceases to satisfy eligibility requirements for health benefits Change in place of residence or worksite of the employee, spouse or dependent Significant change in health benefits and/or premium under NYSHIP Significant change in health benefits and/or premium under employee s or dependent s other employer s plan COBRA events Judgment, decree or order regarding health benefits Medicare or Medicaid eligibility Leaves of absence HIPAA special enrollment rights A request for change in your pre-tax deduction due to a qualifying event must be made within 30 days of the event (or within the waiting period if newly eligible), and delays may be expensive. If you wish to change your pre-tax selection for 2015, see your agency HBA and complete a Health Insurance Transaction Form (PS-404) by November 30, See your agency HBA to change your health insurance option, type of coverage or pre-tax status. NO ACTION IS REQUIRED IF YOU DO NOT WISH TO MAKE CHANGES (unless you wish to continue enrollment in the Opt-out Program; see page 15 for reenrollment requirements). Changes are not automatic and deadlines apply. You must report any change that may affect your coverage to your agency HBA. See pages 1-3 in this booklet and your NYSHIP General Information Book for complete information. Choices 2015/Settled Actives 1

4 YOUR SHARE OF THE PREMIUM The following does not apply to employees of Participating Employers. Participating Employers will provide premium information. It also does not apply to COBRA and Young Adult Option enrollees; they pay the full cost of coverage. New York State helps pay for your health insurance coverage. After the State s contribution, you are responsible for paying the balance of your premium, usually through biweekly deductions from your paycheck. Whether you enroll in The Empire Plan or in a NYSHIP HMO, the State s share and your share of the cost of coverage are based on the following (salary requirements vary; contact your agency HBA for more information): Enrollee s Pay Grade Individual Coverage Dependent Coverage * or salary equivalent, if no Grade assigned. Contact your agency HBA to confirm. State Share Employee Share State Share Employee Share Grade 9 and below* 88% 12% 73% 27% Grade 10 and above* 84% 16% 69% 31% If you enroll in a NYSHIP HMO, the State s dollar contribution for the hospital, medical/surgical and mental health and substance abuse components of your HMO premium will not exceed its dollar contribution for those components of The Empire Plan premium. For the prescription drug component of your HMO premium, the State pays the share noted in the table; the dollar amount is not limited by the cost of Empire Plan drug coverage. As soon as they are available, 2015 rates will be mailed to your home and posted on NYSHIP Online at Select your group if prompted, and then click on Health Benefits & Option Transfer. Choose Rates and Health Plan Choices. LET YOUR AGENCY KNOW ABOUT CHANGES You must notify your agency HBA if your home address or phone number changes. If you are an active employee of New York State and registered for MyNYSHIP, you may also make address and option changes online. Note: MyNYSHIP is not available for active employees of Participating Employers. Changes in your family status, such as gaining or losing a dependent, may mean you need to change your health insurance coverage from Individual to Family or from Family to Individual. If you submit a timely request, you can make most changes any time, not just during the Option Transfer Period. See your NYSHIP General Information Book for details. Inform your agency HBA about any change promptly to ensure it is effective on the actual date of change in family status. RETIRING OR LEAVING STATE SERVICE IN 2015? If you continue your NYSHIP enrollment as a retiree or vestee, you may change your health insurance plan when your status changes. As a retiree or vestee, you may change health insurance options at any time once during a 12-month period. For more information on changing options as a retiree or vestee, ask your agency HBA for 2015 Choices for Retirees. ELIGIBLE FOR MEDICARE? If you or a dependent is eligible for Medicare because of age or disability, see Medicare and NYSHIP on page 5 for important information. Also, please read this section if you or a dependent will be turning age 65 in 2015 or if you are planning to retire in the coming year and will be Medicare primary. 2 Choices 2015/Settled Actives

5 COMPARING YOUR NYSHIP OPTIONS Choosing the option that best meets your needs and the needs of your family requires careful consideration. As with most important purchases, there is more to consider than cost. The first step in making a good choice is understanding the similarities and the differences among your NYSHIP options. There are two types of health insurance plans available to you under NYSHIP: The Empire Plan and NYSHIP HMOs. The Empire Plan is available to all employees. NYSHIP HMOs are available in various geographic areas of New York State. Depending on where you live or work, one or several NYSHIP HMOs will be available to you. The Empire Plan and NYSHIP HMOs are similar in many ways, but also have important differences. Also, if you have other employer-sponsored group health benefits available to you, you may wish to consider the Opt-out Program. (See page 15 for details). BENEFITS The Empire Plan and NYSHIP HMOs All NYSHIP plans provide a wide range of hospital, medical/surgical, and mental health and substance abuse coverage. All plans provide prescription drug coverage if you do not receive it through a union Employee Benefit Fund. All plans provide coverage for certain preventive care services as required by the federal Patient Protection and Affordable Care Act (PPACA). For further information on preventive care services, visit Benefits differ among plans. Read this booklet and the Empire Plan Certificate (available from your agency HBA) and HMO contracts (available from each HMO) carefully for details. EXCLUSIONS All plans contain coverage exclusions for certain services and prescription drugs. Workers compensation-related expenses and custodial care generally are excluded from coverage. For details on a plan s exclusions, read the Empire Plan Certificate, the NYSHIP HMO contract or check with the plan directly. GEOGRAPHIC AREA SERVED The Empire Plan Benefits for covered services, not just urgent and emergency care, are available worldwide. Health Maintenance Organizations (HMOs) Coverage is available in each HMO s specific service area. An HMO may arrange for coverage of care received outside its service area at its discretion in certain circumstances. Choices 2015/Settled Actives 3

6 BENEFITS PROVIDED BY THE EMPIRE PLAN AND ALL NYSHIP HMOS Inpatient medical/surgical hospital care Outpatient medical/surgical hospital services Physician services Emergency services* Laboratory services Radiology services Chemotherapy Radiation therapy Dialysis Diagnostic services Diabetic supplies Maternity, prenatal care Well-child care Chiropractic services Skilled nursing facility services Physical therapy Occupational therapy Speech therapy Prosthetics and durable medical equipment Orthotic devices Bone density tests Mammography Inpatient mental health services Outpatient mental health services Alcohol and substance abuse detoxification Inpatient alcohol rehabilitation Inpatient drug rehabilitation Outpatient alcohol and drug rehabilitation Family planning and certain infertility services (Call The Empire Plan administrators or NYSHIP HMO for details). Out-of-area emergencies Hospice benefits (at least 210 days) Home health care in lieu of hospitalization Prescription drug coverage including injectable and self-injectable medications, contraceptive drugs and devices and fertility drugs (unless you have coverage through a union Employee Benefit Fund) Enteral formulas covered through either HCAP for The Empire Plan or the NYSHIP HMO s prescription drug program (unless you have coverage through a union Employee Benefit Fund) Second opinion for cancer diagnosis Please see the individual plan descriptions in this booklet to review the differences in coverage and out-of-pocket expenses. See plan documents for complete information on benefits. * Some plans may exclude coverage for airborne ambulance services. Call The Empire Plan or your NYSHIP HMO for details. 4 Choices 2015/Settled Actives

7 MEDICARE & NYSHIP If you are an active employee, NYSHIP (The Empire Plan or a NYSHIP HMO) provides primary coverage for you and your dependents, regardless of age or disability. Exceptions: Medicare is primary for domestic partners age 65 or over, or for an active employee or dependent of an active employee with end-stage renal disease (following a 30-month coordination period). NYSHIP requires you and your dependents to be enrolled in Medicare Parts A and B when first eligible for Medicare coverage that pays primary to NYSHIP. If you are planning to retire and you or your spouse is 65 or older, contact your Social Security office three months before active employment ends to enroll in Medicare Parts A and B. Medicare becomes primary to your NYSHIP coverage the first day of the month following a runout period of 28 days after the end of the payroll period in which you retire. If you or a dependent is eligible for Medicare coverage primary to NYSHIP and you don t enroll in Parts A and B, The Empire Plan or HMO will not provide benefits for services Medicare would have paid if you or your dependent had enrolled.* If you are planning to retire or vest in 2015, know how your NYSHIP benefits will be affected when Medicare is your primary coverage: If you are enrolled in original Medicare (Parts A and B) and The Empire Plan: Since Medicare does not provide coverage outside the United States, The Empire Plan pays primary for covered services received outside the United States. If you enroll in a NYSHIP HMO Medicare Advantage Plan: You replace your original (fee-for-service) Medicare coverage with benefits offered by the Medicare Advantage Plan. Benefits and networks under the HMO s Medicare Advantage Plan may differ from your coverage as an active employee. To qualify for benefits, you must follow plan rules. If you enroll in a NYSHIP HMO that coordinates coverage with Medicare: You receive the same benefits from the HMO as an active employee and still qualify for original Medicare benefits if you receive treatment outside your HMO. * If you are asked to pay a Part A premium, see your agency HBA for more information. Medicare Part D is the Medicare prescription drug benefit for Medicare-primary persons. Medicareprimary enrollees and dependents in The Empire Plan are enrolled automatically in Empire Plan Medicare Rx, a Part D prescription drug program. NYSHIP Medicare Advantage HMOs also provide Medicare Part D prescription drug coverage. You can be enrolled in only one Medicare Part D plan at a time. Enrolling in a Medicare Part D plan separate from your NYSHIP coverage may drastically reduce your benefits overall. For example: If you are a Medicare-primary Empire Plan enrollee or dependent and get your prescription drug coverage through Empire Plan Medicare Rx and then you enroll in another Medicare Part D plan outside of NYSHIP, Centers for Medicare & Medicaid Services (CMS) will terminate your coverage in Empire Plan Medicare Rx. Since you must be enrolled in Empire Plan Medicare Rx to maintain Empire Plan coverage, in most cases, this means you and your covered dependents will lose all coverage under The Empire Plan. If you are enrolled in a NYSHIP Medicare Advantage HMO and then enroll in a Medicare Part D plan outside of NYSHIP, Medicare will terminate your enrollment in the NYSHIP Medicare Advantage HMO. If you have been approved for Extra Help by Medicare and you are enrolled in The Empire Plan or a NYSHIP Medicare Advantage HMO, you may be reimbursed for some or all of your Medicare Part D coverage. For information about qualifying for Extra Help, contact Medicare. If you have been approved for Extra Help, contact the Employee Benefits Division or your HMO. If you receive prescription drug coverage through a union Employee Benefit Fund, contact the Fund for information about Medicare Part D. For more information about NYSHIP and Medicare, see your NYSHIP General Information Book or ask your agency HBA for a copy of 2015 Choices for Retirees, Planning for Retirement or Medicare & NYSHIP. Choices 2015/Settled Actives 5

8 THE EMPIRE PLAN OR A NYSHIP HMO WHAT S NEW? All NYSHIP Plans Beginning January 1, 2015, Social Security s definition of spouse will be expanded to include a same-sex spouse for the purpose of determining Medicare primacy. Therefore, an active employee s same-sex spouse, age 65 or older, will be Empire Plan primary, not Medicare primary. The Empire Plan For 2015, the maximum out-of-pocket limit for covered, in-network services under The Empire Plan will be $6,600 for Individual coverage and $13,200 for Family coverage, split between the Hospital, Medical/Surgical, Mental Health and Substance Abuse and Prescription Drug Programs. See table below for more information about how outof-pocket limits apply to each Empire Plan program. Effective January 1, 2014, in accordance with the Patient Protection and Affordable Care Act (PPACA), if The Empire Plan covers a medical service, the Plan must cover it by any provider licensed to render the covered service. Because of this, additional provider types are now covered under The Empire Plan. Unless noted, coverage is limited to non-network and is subject to deductible and coinsurance. Nutritionists and Registered Dieticians now participate with the Plan; please consult the online directory or call the Medical Program for a list of network providers. Beginning October 1, 2014, Empire Plan-primary enrollees and dependents may receive select preventive vaccines without copayment when administered by a licensed pharmacist at a pharmacy that participates in CVS/caremark s national vaccine network. NYS law restricts pharmacists to administering vaccines to patients ages 18 or older. Similar laws may be in place in other states. Beginning January 1, 2015, there will be no annual maximum for applied behavior analysis services for the treatment of autism spectrum disorder. NYSHIP HMOs As of January 1, 2015, GHI HMO will no longer be offered under NYSHIP. HIP will offer coverage for the service areas formerly covered under GHI (220 and 350) with a few important changes. Delaware County will be moving from code 220 to 350, and Rockland County will not be covered under HIP. Remember, benefits differ from HMO to HMO. The benefits offered by GHI HMO will differ from those offered by HIP. If you currently have coverage under GHI, be sure to review your plan materials and any other related mailings carefully and make an informed selection during the Option Transfer Period Empire Plan Maximum Out-of-Pocket Limits for In-Network Services Coverage Type Prescription Drug Hospital, Medical/Surgical Total Program* and Mental Health and Substance Abuse Programs Combined Individual Coverage $2,300 $4,300 $6,600 Family Coverage $4,600 $8,600 $13,200 *Does not apply to Medicare-primary enrollees. 6 Choices 2015/Settled Actives

9 THE EMPIRE PLAN The Empire Plan is a unique plan designed exclusively for New York State s public employees. The Empire Plan has many managed care features, but enrollees are not required to choose a primary care physician and do not need referrals to see specialists. However, certain services, such as hospital and skilled nursing facility admissions, certain outpatient radiological tests, certain mental health and substance abuse treatment /services, home care and some prescription drugs, require preapproval. The New York State Department of Civil Service contracts with qualified companies to administer the Plan. The Empire Plan is self-insured. The Empire Plan provides: Network and non-network inpatient and outpatient hospital coverage for medical, surgical and maternity care Medical and surgical coverage under the Participating Provider Program or the Basic Medical Program and Basic Medical Provider Discount Program if you choose a nonparticipating provider Home care services, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes through the Home Care Advocacy Program (HCAP) Chiropractic treatment and physical therapy coverage through the Managed Physical Medicine Program Inpatient and outpatient mental health and substance abuse coverage Prescription drug coverage Centers of Excellence Programs for cancer, transplants and infertility 24-hour Empire Plan NurseLine SM for health information and support Worldwide coverage Providers Under The Empire Plan, you can choose from over 250,000 participating physicians and other providers and facilities nationwide, and from more than 68,000 participating pharmacies across the United States or a mail order pharmacy. Some Licensed Nurse Practitioners and Convenience Care Clinics participate with The Empire Plan. Be sure to confirm participation before receiving care. CONSIDER COST The following does NOT apply to employees of Participating Employers. Participating Employers will provide premium information. It also does not apply to COBRA and Young Adult Option Enrollees. When considering cost, think about all your costs throughout the year, not just your biweekly paycheck deduction. Keep in mind out-of-pocket expenses you are likely to incur during the year, such as copayments for prescriptions and other services, coinsurance and any costs of using providers or services not covered under the plan. Learn about the coverage plans might provide for expensive health conditions or unexpected or catastrophic illness or injury. Watch for the NYSHIP Rates & Deadlines for 2015 flyer that will be mailed to your home and posted on our web site, as soon as rates are approved. Along with this booklet, which provides copayment information, NYSHIP Rates & Deadlines for 2015 will provide the information you need to determine your annual cost under each of the available plans. Choices 2015/Settled Actives 7

10 The Empire Plan guarantees access to primary care physicians and certain specialists in New York State and specific counties in Connecticut, Massachusetts, New Jersey, Pennsylvania and Vermont that share a border with New York State. Note: This benefit does not apply to enrollees of Participating Employers. NYSHIP HEALTH MAINTENANCE ORGANIZATIONS A Health Maintenance Organization (HMO) is a managed care system in a specific geographic area that provides comprehensive health care coverage through a network of providers. Coverage for services received outside the specified geographic area is limited. HMO enrollees who use doctors, hospitals or pharmacies outside the HMO s network must, in most cases, pay the full cost of services unless authorized by the HMO or in an emergency. Enrollees usually choose a primary care physician (PCP) from the HMO s network for routine medical care and for referrals to specialists and hospitals when medically necessary. HMO enrollees usually pay a copayment as a per-visit fee or coinsurance (percentage of cost). HMOs have no annual deductible. Referrals to network specialists may be required. Claim forms rarely are required. All NYSHIP HMOs provide a wide range of health services. Each offers a specific package of hospital, medical, surgical and preventive care benefits. These services are provided or arranged by the PCP selected by the enrollee from the HMO s staff or physician network. All NYSHIP HMOs cover inpatient and outpatient hospital care at a network hospital and prescription drug coverage.* NYSHIP HMOs are organized in one of two ways: A Network HMO provides medical services through its own health centers as well as outside participating physicians, medical groups and multispecialty medical centers. An Independent Practice Association (IPA) HMO provides medical services through private practice physicians who have contracted independently with the HMO to provide services in their offices. Members enrolling in Network and IPA model HMOs may be able to select a doctor they already use if that doctor participates with the HMO. See the individual HMO pages in this booklet for additional benefit information and to learn which HMOs serve your geographic area. NYSHIP HMOs and Medicare If you are Medicare primary, see page 5 for an explanation of how Medicare affects your NYSHIP HMO coverage. SUMMARY OF BENEFITS AND COVERAGE The Summary of Benefits and Coverage (SBC) is a standardized comparison document required by PPACA. To view a copy of an SBC for The Empire Plan or a NYSHIP HMO, visit If you do not have internet access, call NYSHIP ( ) and select the Medical Program to request a copy of the SBC for The Empire Plan. If you need a NYSHIP HMO SBC, contact the HMO. *Unless prescription drug coverage is provided through a union Employee Benefit Fund. 8 Choices 2015/Settled Actives

11 MAKING A CHOICE Selecting a health insurance plan is an important personal decision. Only you know your family s lifestyle, health, budget and benefit preferences. Think about what health care you and your family might need during the next year. Review the plans and ask for more information. Here are several questions to consider: What is my premium for the health plan? What benefits does the plan have for office visits and other medical care? What is my share of the cost? What benefits does the plan have for prescription drugs? Will the medicine I take be covered under the plan? What is my share of the cost? What type of formulary does the plan have? Am I required to use the mail order pharmacy? (If you receive your drug coverage from a union Employee Benefit Fund, ask the Fund about your benefits). Does the plan cover special needs? How are durable medical equipment and other supplies covered? Are there any benefit limitations? (If you or one of your dependents has a medical or mental health/substance abuse condition requiring specific treatment or other special needs, check on coverage carefully. Don t assume you ll have coverage. Ask The Empire Plan administrators or HMOs about your specific treatment). Are routine office visits and urgent care covered for out-of-area college students or is only emergency health care covered? What benefits are available for a catastrophic illness or injury? What choice of providers do I have under the plan? (Ask if the provider or facilities you use are covered). How would I consult a specialist if I needed one? Would I need a referral? How much paperwork is involved in the health plan? Do I have to fill out forms? THINGS TO REMEMBER Gather as much information as possible. Consider the unique needs of yourself and your family. Compare the coverage and cost of your options. Look for a health plan that provides the best balance of cost and benefits for you. HOW TO USE THE CHOICES BENEFIT CHARTS, PAGES All NYSHIP plans must include a minimum level of benefits (see page 4). For example, The Empire Plan and all NYSHIP HMOs provide a paid-in-full benefit for medically necessary inpatient medical/surgical hospital care at network hospitals. Use the charts to compare plans. The charts list outof-pocket expenses and benefit limitations effective January 1, See plan documents for complete information on benefit limitations. To generate an easy-to-read, side-by-side comparison of the benefits provided by each of the NYSHIP plans in your area, use the NYSHIP Plan Comparison tool, available on the Department of Civil Service web site. Go to our homepage at employee-benefits. Select your group if prompted and then choose Health Benefits & Option Transfer. Click on Rates and Health Plan Choices and then NYSHIP Plan Comparison. Select your group and the counties in which you live and work. Then, check the box next to the plans you want to compare and click on Compare Plans to generate the comparison table. Note: Most benefits described in this booklet are subject to medical necessity and may involve limitations or exclusions. Please refer to plan documents, or call the plans directly for details. IF YOU DECIDE TO CHANGE YOUR PLAN The Empire Plan and NYSHIP HMOs are summarized in this booklet. The Empire Plan is available to all employees. NYSHIP HMOs are available to employees in areas where they live or work. Pick the plans that would serve your needs best and call each plan for details before you choose. If you decide to change your plan: See your agency HBA before the Option Transfer deadline announced in the rate flyer. Complete the necessary Health Insurance Transaction Form (PS-404), or change your option online using MyNYSHIP if you are an active employee of a New York State agency. Note: MyNYSHIP cannot be used to elect the Opt-out Program (See page 15). Choices 2015/Settled Actives 9

12 THE EMPIRE PLAN & NYSHIP HMOS: SIMILARITIES & DIFFERENCES Will I be covered for care I receive away from home? The Empire Plan: Yes. The Empire Plan provides worldwide coverage. However, access to network benefits is not guaranteed. NYSHIP HMOs: Under an HMO, you are always covered for emergency care. Some HMOs may provide coverage for routine care outside the HMO service area. Some HMOs provide coverage for college students away from home if the care is urgent or if follow-up care has been preauthorized. See the Out-of-Area benefit description on each HMO page for more information or contact the HMO directly. If I am diagnosed with a serious illness, can I see a physician or go to a hospital that specializes in my illness? The Empire Plan: Yes. You can use the specialist of your choice. You have Basic Medical Program benefits for nonparticipating providers and Basic Medical Provider Discount Program benefits for nonparticipating providers who are part of The Empire Plan MultiPlan group. (See page 21 for more information on the Basic Medical Provider Discount Program). Your hospital benefits will differ depending on whether you choose a network or non-network hospital. (See page 11 for details). NYSHIP HMOs: You should expect to choose a participating physician and a participating hospital. Under certain circumstances, you may be able to receive a referral to a specialist care center outside the network. Can I be sure I will not need to pay more than my copayment when I receive medical services? The Empire Plan: Your copayment should be your only expense if you receive medically necessary and covered services and you: Use a participating provider 1 ; Receive inpatient or covered outpatient hospital services at a network hospital and follow Benefits Management Program requirements. NYSHIP HMOs: As long as you receive medically necessary and covered services, follow HMO requirements and receive the appropriate referral (if required), your copayment or coinsurance should be your only expense. 1 The Empire Plan does not guarantee that participating providers are available in all specialties or geographic locations. 10 Choices 2015/Settled Actives

13 Can I use the hospital of my choice? The Empire Plan: Yes. You have coverage worldwide, but your benefits differ depending on whether you choose a network or nonnetwork hospital. Your benefits are highest at network hospitals participating in the BlueCross and BlueShield Association BlueCard PPO Program, or for mental health or substance abuse care in the ValueOptions network. Network hospital inpatient: Paid-in-full hospitalization benefits. Network hospital outpatient and emergency care: Subject to network copayments. Non-network hospital inpatient stays and outpatient services: 10 percent coinsurance for inpatient stays and the greater of 10 percent coinsurance or $75 for outpatient services, up to the combined annual coinsurance maximum per enrollee; per enrolled spouse or domestic partner; per all enrolled dependent children combined (see page 20). NYSHIP HMOs: Except in an emergency, you generally do not have coverage at non-network hospitals unless authorized by the HMO. What kind of care is available for physical therapy and chiropractic care? The Empire Plan: You have guaranteed access to unlimited medically necessary care when you follow Plan requirements. NYSHIP HMOs: Coverage is available for a specified number of days/visits each year, as long as you follow the HMO s requirements. What if I need durable medical equipment, medical supplies or home nursing? The Empire Plan: You have guaranteed, paid-in-full access to medically necessary home care, equipment and supplies 2 through the Home Care Advocacy Program (HCAP) when preauthorized and arranged by the Plan. NYSHIP HMOs: Benefits are available and vary depending on the HMO. Benefits may require a greater percentage of cost-sharing. 2 Diabetic shoes have an annual maximum benefit of $500. Note: These responses are generic and highlight only general differences between The Empire Plan and NYSHIP HMOs. Details for each plan are available on individual plan pages beginning on page 18 of this booklet, in the Empire Plan Certificate (available from your agency HBA) and in the HMO contract (available from each HMO). Choices 2015/Settled Actives 11

14 TERMS TO KNOW Coinsurance: The enrollee s share of the cost of covered services; a fixed percentage of medical expenses. Copayment: The enrollee s share of the cost of covered services, which is a fixed dollar amount paid when medical service is received, regardless of the total charge for service. Deductible: The dollar amount an enrollee is required to pay before health plan benefits begin to reimburse for services. Fee-for-service: A method of billing for health care services. A provider charges a fee each time an enrollee receives a service. Formulary: A list of preferred drugs used by a health plan. If a plan has a closed formulary, you have coverage only for drugs that appear on the list. An open or incented formulary encourages use of preferred drugs to non-preferred drugs based on a tiered copayment schedule. In a flexible formulary, brand-name prescription drugs may be assigned to different copayment levels based on value to the plan and clinical judgment. In some cases, drugs may be excluded from coverage under a flexible formulary if a therapeutic equivalent is covered or available as an over-the-counter drug. Health Benefits Administrator (HBA): An individual located in a State agency, often in the Human Resources or Personnel Office, who works with the Employee Benefits Division in the Department of Civil Service to process enrollment transactions and answer health insurance questions. You are responsible for notifying your agency HBA of changes that might affect your enrollment. Health Maintenance Organization (HMO): A managed care delivery system organized to deliver health care services in a geographic area. An HMO provides a predetermined set of benefits through a network of selected physicians, laboratories and hospitals for a prepaid premium. Except for emergency services, you and your enrolled dependents may have coverage only for services received from your HMO s network. See NYSHIP Health Maintenance Organizations on page 8 for more information on HMOs including descriptions of the two different types, Network and Independent Practice Association (IPA), which are offered under NYSHIP. Managed Care: A health care program designed to ensure you receive the highest quality medical care for the lowest cost, in the most appropriate health care setting. Most managed care plans require you to select a primary care physician employed by (or who contracts with) the managed health care system. He/she serves as your health care manager by coordinating virtually all health care services you receive. Your primary care physician provides your routine medical care and refers you to a specialist if necessary. Medicare: A federal health insurance program that covers certain people age 65 or older, disabled persons under 65, and those who have end-stage renal disease (permanent kidney failure). Medicare is directed by the federal Centers for Medicare & Medicaid Services (CMS) and administered by the Social Security Administration. 12 Choices 2015/Settled Actives

15 Medicare Advantage Plan: A Medicare option wherein the plan agrees with Medicare to accept a fixed monthly payment for each Medicare enrollee. In exchange, the plan provides or pays for all medical care needed by the enrollee. If you join a Medicare Advantage Plan, you replace your Original (fee-for-service) Medicare coverage (Parts A and B) with benefits offered by the plan and all of your medical care (except for emergency or out-of-area, urgently needed care) must be provided, arranged or authorized by the Medicare Advantage Plan. All NYSHIP Medicare Advantage HMOs include Medicare Part D drug coverage. The benefits under these plans are set in accordance with federal guidelines for Medicare Advantage Plans. Network: A group of doctors, hospitals and/or other health care providers who participate in a health plan and agree to follow the plan s procedures. New York State Health Insurance Program (NYSHIP): NYSHIP covers over 1.2 million public employees, retirees and dependents and is one of the largest group health insurance programs in the country. The Program provides health care benefits through The Empire Plan or a NYSHIP-approved HMO. Option: A health insurance plan offered through NYSHIP. Options include The Empire Plan and NYSHIP-approved HMOs within specific geographic areas. The Opt-out Program (NYSHIP code #700) is also considered a NYSHIP option. NYSHIP S YOUNG ADULT OPTION During the Option Transfer Period, eligible adult children of NYSHIP enrollees can enroll in the Young Adult Option and current Young Adult Option enrollees will be able to switch plans. This option allows unmarried, young adult children up to age 30 to purchase their own NYSHIP coverage. The premium is the full cost of Individual coverage for the option selected. Young Adult Option Web Site For more information about the Young Adult Option, go to and choose your group. This site is your best resource for information on NYSHIP s Young Adult Option. If you have additional questions, please contact the Employee Benefits Division at or Choices 2015/Settled Actives 13

16 QUESTIONS & ANSWERS Q: Can I join The Empire Plan or any NYSHIPapproved HMO? A: The Empire Plan is available worldwide, wherever you live or work. To enroll or continue enrollment in a NYSHIP-approved HMO, you must live or work in that HMO s service area. If you move permanently out of and/or no longer work in your HMO s service area, you must change options. See Plans by County on pages 16 and 17 and the individual HMO pages in this booklet to check the counties each HMO will serve in Q: How do I find out which providers and hospitals participate? What if my doctor or other provider leaves my plan? A: Check with your providers directly to see whether they participate in The Empire Plan or in a NYSHIP HMO. For Empire Plan provider information: Use the Find a Provider tool at employee-benefits. Select your group if prompted, and then click on Find a Provider. Note: This is the most up-to-date source for provider information. Ask your agency HBA for The Empire Plan Participating Provider Directory. Call The Empire Plan toll free at NYSHIP ( ) and select the appropriate program for the type of provider you need. For HMO provider information: Visit the web sites for provider information (web site addresses are provided on the individual HMO pages in this booklet). Call the telephone numbers on the HMO pages in this booklet. Ask which providers participate and which hospitals are affiliated. If you choose a provider who does not participate in your plan, check carefully whether benefits would be available to you. Ask if you need authorization to have the provider s services covered. In most circumstances, HMOs do not provide benefits for services by nonparticipating providers or hospitals. Under The Empire Plan, you have benefits for participating and nonparticipating providers. Note: You cannot change your plan outside the Option Transfer Period because your provider no longer participates. Q: I have a preexisting condition. Will I have coverage if I change options? A: Yes. Under NYSHIP, you can change your option and still have coverage for a preexisting condition. There are no preexisting condition exclusions in any NYSHIP plan. However, coverage and exclusions differ. Ask the plan you are considering about coverage for your condition. Q: What if I retire in 2015 and become eligible for Medicare? A: Regardless of which option you choose, as a retiree, you and your dependent must be enrolled in Medicare Parts A and B when either of you first becomes eligible for primary Medicare coverage (See page 5). Please note, especially, that your NYSHIP benefits become secondary to Medicare and that your benefits may change. Q: I am a COBRA dependent in a Family plan. Can I switch to Individual coverage and select a different health plan from the rest of my family? A: Yes. As a COBRA dependent, you may elect to change to Individual coverage in a plan different from the enrollee s Family coverage. During the Option Transfer Period, you may enroll in The Empire Plan or choose any NYSHIP-approved HMO in the area where you live or work. Q: I elected the Opt-out Program in Can I switch to NYSHIP coverage for 2015? A: Yes, all options are available during the Option Transfer Period. (See Making a Choice, page 9). 14 Choices 2015/Settled Actives

17 THE OPT-OUT PROGRAM NYSHIP CODE #700 An Opt-out Program is available to eligible employees who have other employer-sponsored group health benefits. If eligible, you may opt out of NYSHIP coverage in exchange for an incentive payment. Note: The State Opt-out Program is not available to employees of Participating Employers, however, a Participating Employer may offer a similar option. The annual incentive payment is $1,000 for opting out of Individual coverage or $3,000 for opting out of Family coverage. The incentive payment is prorated and reimbursed in your biweekly paycheck throughout the year. Note: Opt-out incentive payments are taxable income. Enrollment in the Opt-out Program does not continue automatically from year to year. To be eligible for the incentive payments, you must enroll during each Option Transfer Period and attest to having other coverage for the coming plan year. ELIGIBILITY REQUIREMENTS To be eligible for the Opt-out Program, you must have been enrolled in the Opt-out Program for the prior plan year or enrolled in NYSHIP by April 1 of the prior plan year and remained enrolled through the end of that plan year. If you were newly eligible for NYSHIP coverage in the prior plan year, you must have been continuously enrolled from your first date of eligibility for NYSHIP coverage. To qualify for the Opt-out Program, you must be covered under an employer-sponsored group health insurance plan through other employment of your own or a plan that your spouse, domestic partner or parent has as the result of his or her employment. The other coverage cannot be NYSHIP coverage provided through employment with the State of New York. But, NYSHIP coverage through another employer, such as a municipality, school district or public benefit corporation, qualifies as other coverage. (See your agency HBA for details). Make sure the other employer-sponsored plan will permit you to enroll as a dependent. You are responsible for making sure your other coverage is in effect during the period you opt out of NYSHIP. Note: Participation in the Opt-out Program satisfies the requirement of enrollment in NYSHIP at the time of your retirement. The Opt-out Program is not available to retirees. ELECTING TO OPT OUT If you are currently enrolled in NYSHIP and wish to participate in the Opt-out Program, you must elect to opt out during the annual Option Transfer Period and attest to having other employer-sponsored group health benefits for the next plan year. To elect the Opt-out Program, you must submit a completed New York State Health Insurance Transaction Form (PS-404) and the Opt-out Attestation Form (PS-409). Your NYSHIP coverage will terminate at the end of the plan year and the incentive payments will begin after January 1, If you are a new State employee or a newly benefitseligible employee who has other employer-sponsored group health benefits and wish to participate in the Opt-out Program, you must make your election no later than the first date of your eligibility for NYSHIP. If you become newly eligible for the Opt-out Program as the result of a change in your bargaining unit, you must elect the Opt-out Program within 30 days of the effective date of the change. You must complete and submit the NYS Health Insurance Transaction Form (PS-404) and the Opt-out Attestation Form (PS-409). Once enrolled in the Opt-out Program, you are not eligible for the incentive payment during any period that you do not meet the requirements for the State contribution to the cost of your NYSHIP coverage. Also, if you are receiving the opt-out incentive for Family coverage and your last dependent loses NYSHIP eligibility, you will only be eligible for the Individual payment from that date forward. Reminder: All options are available to you during the Option Transfer Period. If you are currently enrolled in the Opt-out Program, you may choose other NYSHIP coverage or elect to opt out again for Choices 2015/Settled Actives 15

18 THE EMPIRE PLAN NYSHIP CODE #001 This section summarizes benefits available under each portion of The Empire Plan as of January 1, You may also visit /employee-benefits or call toll free NYSHIP ( ), the one number for The Empire Plan. Call to connect to: MEDICAL/SURGICAL PROGRAM UnitedHealthcare Medical and surgical coverage through: Participating Provider Program More than 250,000 physicians and other providers participate; certain services are subject to a $20 copayment. Basic Medical Program If you use a nonparticipating provider, the Program considers up to 80 percent of reasonable and customary charges for covered services after the combined annual deductible is met. After the combined annual coinsurance maximum is met, the Plan pays up to 100 percent of reasonable and customary charges for covered services. See Cost Sharing (beginning on page 20) for additional information. Basic Medical Provider Discount Program If you are Empire Plan-primary and use a nonparticipating provider who is part of The Empire Plan MultiPlan group, you are eligible for a discount (see page 21). Home Care Advocacy Program (HCAP) Paid-in-full benefit for home care, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes. Diabetic shoes have an annual maximum benefit of $500. Guaranteed access to network benefits nationwide. Limited non-network benefits available. (See the Empire Plan Certificate/Reports for details). Managed Physical Medicine Program Chiropractic treatment and physical therapy through a Managed Physical Network (MPN) provider are subject to a $20 copayment. Unlimited network benefits when medically necessary. Guaranteed access to network benefits nationwide. Non-network benefits available. Under the Benefits Management Program, you must call the Medical/Surgical Program for Prospective Procedure Review before an elective (scheduled) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests unless you are having the test as an inpatient in a hospital. (See the Empire Plan Certificate for details). When arranged by the Medical/Surgical Program, a voluntary, paid-in-full Specialist Consultant Evaluation is available. Voluntary outpatient Medical Case Management is available to help coordinate services for catastrophic and complex cases. HOSPITAL PROGRAM Empire BlueCross BlueShield The following benefit level applies for covered services received at a BlueCross and BlueShield Association BlueCard PPO network hospital: Medical or surgical inpatient stays are covered at no cost to you. Hospital outpatient and emergency care are subject to network copayments. When you use a network hospital, anesthesiology, pathology and radiology, provider charges for covered hospital services are paid in full under the Medical/ Surgical Program if The Empire Plan provides your primary coverage. Certain covered outpatient hospital services provided at network hospital extension clinics are subject to hospital outpatient and emergency care copayments. Physician charges for covered services received at a hospital extension clinic will be paid in full if the provider is a Participating Provider under the Medical/ Surgical Program. Physician charges for covered services received from a non-network provider will be paid in accordance with the Basic Medical portion of the Medical/Surgical Program. 1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate and Empire Plan Reports/Certificate Amendments. 18 Choices 2015/Settled Actives

19 The following benefit level applies for hospital services received at non-network hospitals (for Empire Planprimary enrollees only 2 ): Non-network hospital inpatient stays and outpatient services 10 percent coinsurance for inpatient stays and the greater of 10 percent coinsurance or $75 for outpatient services, up to the combined annual coinsurance maximum per enrollee; per enrolled spouse or domestic partner; per all enrolled dependent children combined (See page 20). The Empire Plan will approve network benefits for hospital services received at a non-network facility if: Your hospital care is emergency or urgent. You do not have access to a network facility within 30 miles of your residence. No network facility can provide the medically necessary services. Another insurer or Medicare provides your primary coverage (pays first). Preadmission Certification Requirements Under the Benefits Management Program, if The Empire Plan is your primary coverage, you must call the Hospital Program for certification of any inpatient stay: before a maternity or scheduled (nonemergency) hospital admission, within 48 hours or as soon as reasonably possible after an emergency or urgent hospital admission, and before admission or transfer to a skilled nursing facility. If you do not follow the preadmission certification requirement for the Hospital Program, you must pay: a $200 hospital penalty if it is determined any portion was medically necessary, and all charges for any day s care determined not to be medically necessary. Voluntary inpatient Medical Case Management is available to help coordinate services for catastrophic and complex cases. MENTAL HEALTH AND SUBSTANCE ABUSE PROGRAM ValueOptions, Inc. The Mental Health and Substance Abuse Program (MHSA) offers two levels of benefits. If you call the MHSA Program before you receive services and follow their recommendations, you receive: Network Benefits (unlimited when medically necessary) Inpatient (paid in full) Crisis intervention (up to three visits per crisis paid in full) Outpatient including office visits, home-based or telephone counseling and nurse practitioner services, subject to a $20 copayment Outpatient rehabilitation to an approved Structured Outpatient Rehabilitation Program for substance abuse, subject to a $20 copayment If you do NOT follow the requirements for network coverage, you receive: Non-network Benefits 3 (unlimited when medically necessary) For Practitioner Services: the MHSA Program will consider up to 80 percent of reasonable and customary charges for covered outpatient practitioner services after you meet the combined annual deductible per enrollee; per enrolled spouse or domestic partner; per all enrolled dependent children combined. After the combined annual coinsurance maximum is reached per enrollee; per enrolled spouse or domestic partner; per all enrolled dependent children combined, the Plan pays up to 100 percent of reasonable and customary charges for covered services (see page 20). For Approved Facility Services: You are responsible for 10 percent of covered billed charges up to the combined annual coinsurance maximum per enrollee; per enrolled spouse or domestic partner; per all enrolled dependent children combined. After the coinsurance maximum is met, the Plan pays 100 percent of billed charges for covered services (See page 20). 2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals. 3 You are responsible for obtaining MHSA Program certification for care obtained from a non-network practitioner or facility. Choices 2015/Settled Actives 19

20 THE EMPIRE PLAN NYSHIP CODE #001 Outpatient treatment sessions for family members of an alcoholic, alcohol abuser or substance abuser are covered for a maximum of 20 visits per year for all family members combined. EMPIRE PLAN COST SHARING Plan Providers Under The Empire Plan, benefits are available for covered services when you use a participating or nonparticipating provider. However, your share of the cost of covered services depends on whether the provider you use is participating under the Plan. If you use an Empire Plan participating or network provider or facility, you pay a copayment for certain services; some are covered at no cost to you. The provider or facility files the claim and is reimbursed by The Empire Plan. You are guaranteed access to network benefits when you contact the program before receiving services and follow program requirements for: Mental Health and Substance Abuse Program services; Managed Physical Medicine Program services (physical therapy and chiropractic care); and Home Care Advocacy Program (HCAP) services (including durable medical equipment) Annual Maximum Out-of-Pocket Limit Your maximum out-of-pocket expenses for in-network covered services will be $4,300 for Individual coverage and $8,600 for Family coverage for Hospital, Medical/ Surgical and Mental Health and Substance Abuse programs, combined. Once you reach the limit, you will have no additional copays. If you use a nonparticipating provider or non-network facility, benefits for covered services are subject to a deductible and/or coinsurance. Combined Annual Deductible For medical/surgical and mental health and substance abuse services, The Empire Plan has a combined annual deductible of $1,000 per enrollee, $1,000 per enrolled spouse/domestic partner and $1,000 per all dependent children combined. The combined annual deductible must be met before covered services under the Basic Medical Program and non-network expenses under both the Home Care Advocacy Program (HCAP) and Mental Health and Substance Abuse (MHSA) Program can be reimbursed. The Managed Physical Medicine Program has a separate $250 deductible per enrollee, $250 per enrolled spouse/domestic partner and $250 per all dependent children combined that is not included in the combined annual deductible. The $1,000 combined annual deductible amount will be reduced to $500 per calendar year for employees in or equated to Salary Grade 6 or below on January 1, Note: This reduction is not available to Judges and Justices or employees of Participating Employers. After you satisfy the combined annual deductible, The Empire Plan pays 80 percent of the reasonable and customary charge for the Basic Medical Program and non-network practitioner services for the MHSA Program and 90 percent of covered services for the non-network HCAP services and non-network approved facility services for the MHSA Program. You are responsible for the remaining 20 percent coinsurance and all charges in excess of the reasonable and customary charge for Basic Medical Program and non-network practitioner services. You also are responsible for the remaining 10 percent coinsurance for non-network HCAP services and non-network MHSA-approved facility services. Combined Annual Coinsurance Maximum The Empire Plan has a combined annual coinsurance maximum of $3,000 per enrollee, $3,000 per enrolled spouse/domestic partner and $3,000 per all dependent children combined. After you reach the combined annual coinsurance maximum, you will be reimbursed up to 100 percent of the reasonable and customary charge. You are responsible for paying the provider and will be reimbursed by the Plan for covered charges. The $3,000 combined annual coinsurance maximum will be reduced to $1,500 per calendar year for employees in or equated to Salary Grade 6 or below. Note: This reduction is not available to Judges and Justices or employees of Participating Employers. 20 Choices 2015/Settled Actives